As infection prevention and healthcare epidemiology continue to undergo a dramatic transformation in duties and responsibilities, resources and program support are lagging in many hospitals even as a Zika virus outbreak follows closely on the heels of Ebola.
“At present, many healthcare institutions are under-resourced, with insufficient reimbursement for hospital epidemiology (HE) services and too few IPs,” the authors of recently published study1 reported. “Yet there is ample evidence that a comprehensive IPC/HE program can reduce healthcare-associated infections (HAIs), minimize the spread of MDROs, and address emerging infections and pathogens, ultimately keeping patients safer.”
The white paper by the Society for Healthcare Epidemiology of America (SHEA) also includes input from the Association for Professionals in Infection Control and Epidemiology (APIC). In a related development, as public health officials called the field to action again on another daunting issue — staving off a post-antibiotic era — APIC said more must be done, but resources are a continuing problem.
“APIC believes that the U.S. must do more to protect the 2 million Americans who develop infections from antibiotic-resistant bacteria each year and the 23,000 who will die as a result,” the association said in a statement. “With the ongoing threat of emerging infectious diseases and antibiotic-resistant organisms, APIC remains concerned that many facilities are lagging behind in providing adequate support to protect patients and healthcare workers. Unfortunately, many healthcare facilities do not have enough staff dedicated to infection prevention and control. A recent APIC survey found that one in two hospitals had only one or less than one full-time equivalent infection preventionist on staff.”
IPs should clearly review their departments accomplishments and future challenges before approaching the C-suite with a request for more resources, says Sue Dolan, RN, MS, CIC, hospital epidemiologist at Children’s Hospital (Aurora) Colorado and 2016 APIC president.
“The IP clearly needs to identify where the program is and where the program needs to go,” she told Hospital Infection Control & Prevention. “They need to share that information to help leadership understand what resources are needed to get there. It’s not just walking in, saying, ‘I need another IP. I need an epidemiologist.’ It’s, ‘Here’s where we are, here’s where we need to go, and here’s the resources that we need to get there.’ We worked together with SHEA to develop a program [description in the article] so the infection preventionist and the epidemiologist can have this conversation with senior leadership in their organization.”
As described in the paper, the scope of a healthcare institution’s infection prevention and control/healthcare epidemiology program should be driven by the size and complexity of the patient population served, that population’s risk for HAIs, and local, state, and national regulatory and accreditation requirements. Essential activities of all IPC/HE programs include but are not limited to the following:
- performance improvement to reduce HAIs,
- acute event response, including outbreak investigation,
- education and training of both healthcare personnel and patients, and
- reporting of HAIs to the CDC National Healthcare Safety Network as well as entities required by law.
The program may be involved in a number of other activities depending on the needs of the organization, the annual risk assessment, and resources available. The effective program must be multidisciplinary and include experts in both healthcare epidemiology and infection prevention. Expertise is defined by sets of core competencies established by SHEA and APIC. Program personnel must have authority delegated from institutional leadership to perform essential activities and implement changes to reduce HAIs. The number of personnel is not determined solely by the number of patients served by a given facility, but rather by the scope and complexity of program activities.
“The budget allocated for the program must support adequate numbers of personnel (infection preventionists and healthcare epidemiologists) to execute program activities,” the authors emphasized.
CHANGE AND CHALLENGE
The last two decades have seen a wide variety of new challenges emerge for infection control and healthcare epidemiology, including the following:
- legislative mandates,
- public reporting,
- pay-for-performance, payment penalties,
- HAI prevention collaboratives,
- bioterrorism (i.e., anthrax attacks),
- new and emerging pathogens such as pandemic H1N1 flu, MERS, and Ebola,
- Occupational Safety and Health Administration (OSHA) mandates,
- first National Action Plan to reduce HAIs,
- rise of multidrug-resistant organisms (MDROs), and
- unprecedented antimicrobial shortages and lack of new drugs.
“Meeting these regulatory and accreditation requirements along with increasingly frequent legislative mandates for HAI data requires a substantial investment of resources and is a key element of an effective IPC/HE program,” the authors wrote. “In addition, CMS, under its inpatient quality reporting, is currently requiring acute care providers to report CLABSI, catheter-associated urinary tract infections, and select surgical site infections, as well as hospital-onset Clostridium difficile infection and hospital onset methicillin-resistant Staphylococcus aureus bloodstream infection. …The Affordable Care Act provisions include a mandate that facilities within the highest quartile for certain infections be penalized 1% of their Medicare reimbursement.”
In addition, CMS Conditions of Participation 482.42(a) states, “A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases. … The interpretive guidelines for 482.42(b) state that it is the responsibility of the chief executive officer, the medical staff, and the director of nursing to implement successful corrective action plans for problems identified through the infection prevention program.”
Similarly, The Joint Commission Standard IC.01.01.01 requires an individual with clinical authority over the infection prevention program to have responsibility for developing a system for identifying, reporting, investigating, and controlling infections and communicable diseases, the authors added.
While there are plenty of regulatory incentives for hospital administrators to support infection control, there is also one real-world reason: Efforts to reduce HAIs and protect patients from all manner of infectious threats are not likely to be successful without support from senior administration. Period.
For example, the principal investigator behind implementation of a checklist for central line insertion that ultimately saved thousands of patients’ lives said it could not have been done without an entire organizational commitment.
“We went into hospitals that had very low bloodstream infections and those that were not able to get low to see what differentiated those two,” says Peter Pronovost, MD, PhD, FCCM, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine in Baltimore. “We found that it wasn’t one thing, but there were some very specific things that hospitals did. Number one, the leaders declared and committed a goal of zero preventable infections. Number two, they supported creating and enabling infrastructure. They worked with the infection prevention team and quality and safety people to support clinicians.”
Moreover, in a recent call to action at a press conference on the threat of antibiotic resistance, CDC Director Tom Frieden, MD, MPH, said, “CEOs [and] administrators are a major part of the solution. It’s important that they make a priority of infection prevention, sepsis prevention, and antibiotic stewardship. Know your facility’s data and target prevention efforts to assure improvements in patient safety.”
- Bryant KA, Harris AD, Gould CV, et al. MD, Necessary Infrastructure of Infection Prevention and Healthcare Epidemiology Programs: A Review. Infect Control Hosp Epidemiol 2016;1:1-10.